86217A - Grossser, Adam

❑ CAMA ❑ DREDGE & FILL
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N° 86217
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GENERAL PERMIT
permit
DatePrevious
eviou
Date previous permit issued
New ❑ Modification ❑ Complete Reissue
❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC Jai / _2- ❑ Rules attached.
General Permit Rules available at the following link: www.dgq..ncYov//CAMArules
Applicant Name (`^, `- > -S s e. r
Authorized Agent V o
t .J) O ,h Q7
�Q n'f i L t Al
Address 3 / -5t1 o A , i ( � r, a J
Project Location (County):
` D a -1Z
1I
City 6 1/ 15 b D f J 0 State A zip 7 y^/
Street Address/State Road/Lot #(s)
Phone # (1 1) � tc 3 ik
c� / ? 1( 1 7 Z l-f 10 ,
! % J o � � � � Lt r. �
CA 51 V A.,
Email Ck K y �- 5 `' e r � �
Subdivision L S ��'
� � (._lr. � r S �Lt 2
City 0 ay Q S
ZIP 2—
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS
/
Adj. Wtr. Body ! < =_ SO el
�nat(man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS
Closest Maj. Wtr. Body
/1111. rh , Sa u n C(
ORW: yes/noi PNA: yes/no
Type of Project/ Activity 1,o 3':r , c: ' /l. : c L- {+ e {, <.� ;a /c f r!r, c „1 .S %� s , y� �� x
,� k / ., , ,� ti-�, v _� (Scale: NTS )
Shoreline Length
T--7 -7-7:��
Access Length i
i
Pier (dock) length J
Fixed Platform(s) C -
s i }
111
Floating Platform(s)
W er ie s
Total Platform area
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/ length
i
Basin, channel ,
dA..... . . . . . . .
Cubic yards. x
Boat ramp
Boathouse/ Boatlift a —
Beach Bulldozing
Other _
t
SAV observed: yes noL,
Moratorium: n/a yes no
Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by:
Permit Conditions
a
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit"
Application Fee(s) Check #/Money Order
Signature
Issuing Date
Expiration Date

a
AMA / ❑ DREDGE & FILL N9 83948 ti..1 B C D
ENERAL PERMIT Previous permit#
ew OModification ❑Complete Reissue OPartial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality /1
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC Zl7 / d ��
ll Ues attached.
Applicant Name A G 0.fr-- & (-O SS +sr- Project Location: County ,T ('U('r+i...
t3lAddress,! , t �2,�t : i4 v�. Stre t A-d�d-ryess/ State Road/ Lot #(s)
tI' State ZIP c3/tG Ilii7�tGx.S.To. its•�c•1� room/7a's�
Ci S s, �v.
Phone # (�) 8.(0.T-�Zll,-Mail _ _ Subdivision
Authorized Agent ` v3,-- V A f 0.r1 4-kA c Eity, City Q11'i r Zip W ?
Affected 14Cw TA OES ❑PTS Phone # ( )_"` River Basin S' s
a OEA ❑ HHF C] 11`H o UBA o N/A •� a� n - an unkn
AEC(s}: Adj. Wtr. Body /h �'t �:�
a Pws;
ORW: yes / o PNA yes / Sb Closest Mal. Wtr. Body
Type of Project/ Activity a rs cam`
L"t ,e,o,.4' 2- S .. S-y o ` (,r 9--da4,e t,S - i+ k-i 0. o (Scale:
Pier (dock)
Fixed Platform(s) �l6 r JE i
Floating Platform(s)
Finger piers).
Groinlength3 f
_
number `-
{{
Bulkhead/ Riprap length
..
avg distance offshore
max distance offshore
i
Basin, channel 1\ T,
a
cubic yards
Boatramp..W.._.._..W,..___.._ .w....._..._..�1
Boathouse/ Boatlift
Beach Bulldozing
Other / (D. )L
pSal W eJer t
ll,"7H a4aG6�
Shoreline Length
SAV: not sure yes no t !�
Moratorium: n!a yes no
Photos: ye no l
Waiver Attached: yes
A building permit may be required by: ci. ❑ See note on back regarding River Basin rules.
( Note Local Planning Jurisdiction) L t )
Notes/ Special Conditions 54-r k" t " r4 /6• vL5 `J �r f t-✓a. � °�"� % x-o. S `C" 3 �e t'`� o� �� iis'
0.A4 ,Sft-"T'I. ern.d- Su
Agent or Applicant Printed ame
Signature" Please read compliance statement on back of permit's
Application Fee(s) Cheek #
d
0
PermitOfficer's Printed Name
Si 90
ur
Issuing Date Expiration Date

DocuSign Envelope ID: 90753F72-D005-46DB-BF00-A4917F1 BOFA3
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONfWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner:
Address of Property
Mailing Address of Owner:
Adam Grosser
0 Thalassa Ave Waves, NC 27982
315 Pine Hill Road, Hillsborough, CA 94010
Owner's email: adamgrosser.com Owner's Phone#: [phone]
Agent's Name: Doug Dorman Agent Phone#
Agent's Email: [e-mail]
252-599-2603
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
I DO NOT have objections to this proposal. I DO have objections to this proposal.
if you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
,,—DoeuSgmd by:
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: Carol Dickinson
Mailing Address of ARPO:
381 S. Columbia Ave., Columbus, OH 42309
ARPO's email: [e-mail] ARPO's Phone#: [phone]
Date: 08/31 /21 *waiver is valid for up to one year from ARPO's Signature*
Revised May 2021

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the maiipiece,
or on the front if space permits.
1. Article Addressed to:
64-D
A. Signature
/I ❑ Agent
❑ Addre
B. R",;; by (Printed Name) C. at f Del
D. /IIsss deliveryaddressdifferent from item ? ❑
If YES, enter delivery address below: ❑ No
a.►��i �- Z��i 7��s�r�t�,�.-,,,yrg�� I
v 3. Service Type ❑ Priority Mail EwVWO
❑ Signature Restricted Delivery ❑ R Mail Restricted
❑ Certified Mafi Restricted Delivery ❑ Signature cm*mat*nTM
9590 9402 6345 0296 2441 19 ❑ caW on DeWery ❑ signature Confirmation
_2-ArildaNumber (fay fer from service Lab ❑ Coliea on Delivery Restrbted Delivery Restricted Delivery
- - - Mail
7020 3160 0001 2522 9558 _��'Restrict
edDe1 er'
PS Form 3811, July 2020 PSN 7530-02-000-9053 Domestic Return Receipt

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ADAM GROSSER
CAMA GENERAL PERMIT FOR PIER AND
LOT 1 OR
SALVO — DARE COUNTY — NORTH CAROLINA
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GRAPHIC SCALE 1*= 100' p A AV im AMY #A
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FILE: GROSSER 2021 DAN 08/19/21 REMSEM

AUTHORIZATION TO ACT AS REPRESENTATIVE FORM
Property Legal Description:
DEED BOOK: 1332 PAGE NO: 375
PIN NO.: 064708973673 & 064089774515
PROPERTY STREET ADRESS: Thalassa Ave. Waves, NC 27982. _
Please Print:
Property Owner: Adam Grosser
Property Owner:
The undersigned property owners of the above noted property, so hereby authorize
Doug Dorman of Atlantic Environmental Consultants, LLC to,
(Contractor/Agent) (Name of consulting firm)
1. Act on my behalf and take all actions necessary for the processing, issuance and
acceptance of permits and/or certifications and any all standard and special
conditions attached.
2. Enter the property to obtain site information including inspections with regulatory
agencies (Dare County, North Carolina Department of Environmental Quality,
U.S. Army Corps of Engineers, etc.) for the purpose of obtaining permits and/or
certifications.
Property Owners Address (if different than property above):
315 Pinehill Road. Hillsborough. CA 94010
Property Owners Telephone Number: 650-863-6700
We hereby certify that the above information submitted in this application is true and
urate tot est of our knowledge.
Aut orized Si re and TitleC��-'~-P'� Authorized Signature and Title
Date: � 1 e I k Date:

9